Pneumonia

Pneumonia is an illness of the lungs and respiratory system in which the alveoli
(microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere)
become inflamed and flooded with fluid. Pneumonia can result from a variety of causes,
including infection with bacteria, viruses, fungi, or parasites, and chemical or physical injury to
the lungs.

Typical symptoms associated with pneumonia include cough, chest pain, fever, and
difficulty in breathing. Diagnostic tools include x-rays and examination of the sputum. Treatment
depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotics.

Pneumonia is a common illness which occurs in all age groups, and is a leading cause of
death among the elderly and people who are chronically and terminally ill. Vaccines to prevent
certain types of pneumonia are available. The prognosis depends on the type of pneumonia, the
appropriate treatment, any complications, and the person's underlying health.

Bacteria

Bacteria typically enter the lung when airborne droplets are inhaled, but can also reach
the lung through the bloodstream when there is an infection in another part of the body. Many
bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and
can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between cells
and between alveoli through connecting pores. This invasion triggers the immune system to
send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils engulf and
kill the offending organisms, and also release cytokines, causing a general activation of the
immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal
pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli
and interrupt normal oxygen transportation.

The bacterium Streptococcus pneumoniae, a common cause of pneumonia,

photographed through an electron microscope.

Bacteria often travel from an infected lung into the bloodstream, causing serious or
even fatal illness such as septic shock, with low blood pressure and damage to multiple parts of
the body including the brain, kidneys, and heart. Bacteria can also travel to the area between
the lungs and the chest wall (the pleural cavity) causing a complication called an empyema.

The most common causes of bacterial pneumonia are Streptococcus pneumoniae,

Gram-positive bacteria and "atypical" bacteria. The terms "Gram-positive" and "Gram-negative"
refer to the bacteria's color (purple or red, respectively) when stained using a process called the
Gram stain. The term "atypical" is used because atypical bacteria commonly affect healthier
people, cause generally less severe pneumonia, and respond to different antibiotics than other
bacteria.

The types of Gram-positive bacteria that cause pneumonia can be found in the nose or
mouth of many healthy people. Streptococcus pneumoniae, often called "pneumococcus", is the
most common bacterial cause of pneumonia in all age groups except newborn infants. Another
important Gram-positive cause of pneumonia is Staphylococcus aureus. Gram-negative bacteria
cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative
bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella pneumoniae,
Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in
the stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which
cause pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and
Legionella pneumophila.

Viruses

Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when
airborne droplets are inhaled through the mouth and nose. Once in the lungs, the virus invades
the cells lining the airways and alveoli. This invasion often leads to cell death, either when the
virus directly kills the cells, or through a type of cell self-destruction called apoptosis. When the
immune system responds to the viral infection, even more lung damage occurs. White blood
cells, mainly lymphocytes, activate certain chemical cytokines which allow fluid to leak into the
alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal
transportation of oxygen into the bloodstream.

As well as damaging the lungs, many viruses affect other organs and thus disrupt many
body functions. Viruses can also make the body more susceptible to bacterial infections; for
which reason bacterial pneumonia often complicates viral pneumonia.
 Viral pneumonia is commonly caused by viruses such as influenza virus, respiratory
syncytial virus (RSV), adenovirus, and metapneumovirus. Herpes simplex virus is a rare cause of
pneumonia except in newborns. People with immune system problems are also at risk of
pneumonia caused by cytomegalovirus (CMV).

Fungi

Fungal pneumonia is uncommon, but it may occur in individuals with immune system
problems due to AIDS, immunosuppresive drugs, or other medical problems. The
pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungal
pneumonia is most often caused by Histoplasma capsulatum, Cryptococcus neoformans,
Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the
Mississippi River basin, and coccidioidomycosis in the southwestern United States.

Parasites

A variety of parasites can affect the lungs. These parasites typically enter the body
through the skin or by being swallowed. Once inside, they travel to the lungs, usually through
the blood. There, as in other cases of pneumonia, a combination of cellular destruction and
immune response causes disruption of oxygen transportation. One type of white blood cell, the
eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to
eosinophilic pneumonia, thus complicating the underlying parasitic pneumonia. The most
common parasites causing pneumonia are Toxoplasma gondii, Strongyloides stercoralis, and
Ascariasis.

Symptoms

Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching the
bloodstream. The alveolus on the left is normal, while the alveolus on the right is full of fluid
from pneumonia.

People with infectious pneumonia often have a cough producing greenish or yellow
sputum and a high fever that may be accompanied by shaking chills. Shortness of breath is also
common, as is pleuritic chest pain, a sharp or stabbing pain, either felt or worse during deep
breaths or coughs. People with pneumonia may cough up blood, experience headaches, or
develop sweaty and clammy skin. Other possible symptoms are loss of appetite, fatigue,
blueness of the skin, nausea, vomiting, mood swings, and joint pains or muscle aches. Less
common forms of pneumonia can cause other symptoms; for instance, pneumonia caused by
Legionella may cause abdominal pain and diarrhea, while pneumonia caused by tuberculosis or
Pneumocystis may cause only weight loss and night sweats. In elderly people manifestations of
pneumonia may not be typical. They may develop a new or worsening confusion or may
experience unsteadiness, leading to falls. Infants with pneumonia may have many of the
symptoms above, but in many cases they are simply sleepy or have a decreased appetite.

DIAGNOSTIC STUDIES

Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple
abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or
diffuse/extensive nodular infiltrates(more often viral). In mycoplasmal pneumonia, chest x-ray
may be clear.

Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic (re-
expansion of lung segment).

ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung involvement

and underlying lung disease.

Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and

transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover
causative organism. More than one type of organism may be present; common bacteria include
Diplococcus pneumoniae, Staphylococcus aureus, ahemolytic streptococcus, Haemophilus
influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending
organisms. Blood cultures may show transient bacteremia.

CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be present
in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial
pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.

Serologic studies, e.g., viral or Legionella titers, cold agglutinins: Assist in differential diagnosis
of specificorganism.

Pulmonary function studies: Volumes may be decreased (congestion and alveolar collapse);
airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).

Electrolytes: Sodium and chloride levels may be low.

Bilirubin: May be increased.

Percutaneous aspiration/open biopsy of lung tissues: May reveal typical intranuclear and
cytoplasmic inclusions (CMV), characteristic giant cells (rubeola).Pathophysiology
Community-acquired pneumonia

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not

recently been hospitalized. CAP is the most common type of pneumonia. The most common
causes of CAP differ depending on a person's age, but they include Streptococcus pneumoniae,
viruses, the atypical bacteria, and Haemophilus influenzae. Overall, Streptococcus pneumoniae
is the most common cause of community-acquired pneumonia worldwide. Gram-negative
bacteria cause CAP in certain at-risk populations. CAP is the fourth most common cause of death
in the United Kingdom and the sixth in the United States. An outdated term, walking
pneumonia, has been used to describe a type of community-acquired pneumonia of less
severity (hence the fact that the patient can continue to "walk" rather than require
hospitalization). Walking pneumonia is usually caused by a virus or by atypical bacteria.

Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia

acquired during or after hospitalization for another illness or procedure with onset at least 72
hrs after admission. The causes, microbiology, treatment and prognosis are different from those
of community-acquired pneumonia. Up to 5% of patients admitted to a hospital for other causes
subsequently develop pneumonia. Hospitalized patients may have many risk factors for
pneumonia, including mechanical ventilation, prolonged malnutrition, underlying heart and lung
diseases, decreased amounts of stomach acid, and immune disturbances. Additionally, the
microorganisms a person is exposed to in a hospital are often different from those at home .
Hospital-acquired microorganisms may include resistant bacteria such as MRSA, Pseudomonas,
Enterobacter, and Serratia. Because individuals with hospital-acquired pneumonia usually have
underlying illnesses and are exposed to more dangerous bacteria, it tends to be more deadly
than community-acquired pneumonia. Ventilator-associated pneumonia (VAP) is a subset of
hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of
intubation and mechanical ventilation.

Other types of pneumonia

Severe acute respiratory syndrome (SARS)

SARS is a highly contagious and deadly type of pneumonia which first occurred in 2002
after initial outbreaks in China. SARS is caused by the SARS coronavirus, a previously unknown
pathogen. New cases of SARS have not been seen since June 2003.

ronchiolitis obliterans organizing pneumonia (BOOP)

BOOP is caused by inflammation of the small airways of the lungs. It is also known as
cryptogenic organizing pneumonitis (COP).

Eosinophilic pneumonia
 Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind of white
blood cell. Eosinophilic pneumonia often occurs in response to infection with a parasite or after
exposure to certain types of environmental factors.

Chemical pneumonia

Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxins

such as pesticides, which may enter the body by inhalation or by skin contact. When the toxic
substance is an oil, the pneumonia may be called lipoid pneumonia.

Aspiration pneumonia

Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreign objects

which are usually oral or gastric contents, either while eating, or after reflux or vomiting which
results in bronchopneumonia.[6] The resulting lung inflammation is not an infection but can
contribute to one, since the material aspirated may contain anaerobic bacteria or other unusual
causes of pneumonia. Aspiration is a leading cause of death among hospital and nursing home
patients, since they often cannot adequately protect their airways and may have otherwise
impaired defenses.

Treatment

Most cases of pneumonia can be treated without hospitalization. Typically, oral

antibiotics, rest, fluids, and home care are sufficient for complete resolution. However, people
with pneumonia who are having trouble breathing, people with other medical problems, and
the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia
does not improve with home treatment, or complications occur, the person will often have to be
hospitalized.

Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful
for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections
that can occur in lungs damaged by a viral pneumonia. The antibiotic choice depends on the
nature of the pneumonia, the most common microorganisms causing pneumonia in the local
geographic area, and the immune status and underlying health of the individual. Treatment for
pneumonia should ideally be based on the causative microorganism and its known antibiotic
sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even
after extensive evaluation. Because treatment should generally not be delayed in any person
with a serious pneumonia, empiric treatment is usually started well before laboratory reports
are available. In the United Kingdom, amoxicillin is the antibiotic selected for most patients with
community-acquired pneumonia, sometimes with added clarithromycin; patients allergic to
penicillins are given erythromycin instead of amoxicillin. In North America, where the "atypical"
forms of community-acquired pneumonia are becoming more common, azithromycin,
clarithromycin, and the fluoroquinolones have displaced amoxicillin as first-line treatment. The
duration of treatment has traditionally been seven to ten days, but there is increasing evidence
that shorter courses (as short as three days) are sufficient.[7][8][9]

Antibiotics for hospital-acquired pneumonia include vancomycin, third- and fourth-

generation cephalosporins, carbapenems, fluoroquinolones, and aminoglycosides. These
antibiotics are usually given intravenously. Multiple antibiotics may be administered in
combination in an attempt to treat all of the possible causative microorganisms. Antibiotic
choices vary from hospital to hospital because of regional differences in the most likely
microorganisms, and because of differences in the microorganisms' abilities to resist various
antibiotic treatments.

People who have difficulty breathing due to pneumonia may require extra oxygen.
Extremely sick individuals may require intensive care treatment, often including intubation and
artificial ventilation.

Viral pneumonia caused by influenza A may be treated with rimantadine or amantadine,

while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir.
These treatments are beneficial only if they are started within 48 hours of the onset of
symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have
shown resistance to rimantadine and amantadine. There are no known effective treatments for
viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza
virus.
 DEMOGRAPHIC DATA

Patient’s Name: Dyosa

Age: 63 y/o

Sex: Female

Date of Birth: October 5, 1945

Place of Birth: Pangal Norte, Echague, Isabela

Citizenship: Filipino

Religion: Roman Catholic

Civil status: widow

Address: San Salvador, Echague, Isabela

Educational Attainment: Elementary Graduate

Date of Admission: 10/06/08

Time of Admission: 9:00 AM

Mode of Admission: Ambulatory

Chief Complaints: fever x 7 days, cough and body weakness

Vital Signs upon admission: BP- 130/80 mmHg, RR- 30 cpm, PR 124 bpm, Temp.- 37.9 C

Admitting Diagnosis: t/c Pneumonia

Attending Physician: Dra. Ventura

 Nursing History

History of Present Illness

Seven days PTA, patient complained of fever, cough and body weakness. She tried to treat this
with over the counter drugs but the symptoms kept on recurring. On October 06, 2008, her fever and
cough was intolerable so her daughter decided to seek medical attention. So on October 06, 2008 at 9:00
AM, patient was admitted and confined at Echague District Hospital for further management and
evaluation. Upon admission, patient underwent blood test. Chest x-ray and blood typing the following
day.

Past Health History

(+) Frequent coughs and cold

(+) alcohol drinker and smokers

(-) Allergies to food and drugs

(-) Childhood immunizations

Family History

Father Mother

Hypertension + +

Asthma - -

Cancer - -

DM + -
Nutritional and Metabolic Pattern

Prior to admission, patient eats three times a day usually composed of meat or fish, sometimes,
vegetables. She never exhibited any difficulty with regards to chewing and mastication. Patient drinks at
about 4-6 glasses of water a day.

During hospitalization, she was placed at diet as tolerated (DAT). She eats less than her usual diet
because of discomfort and loss of appetite. Intravenous fluids are given to facilitate better hydration and
supplemental nourishments (D5 LR @ 1L x 8 hours).

Elimination Pattern

Prior to admission, patient defecates one to two times a day and urinates 4-6 times a day. She
never experienced any difficulties with regards to her voiding patterns.

During hospitalization, patient’s defecation frequency decreases due to inadequate food intake.
Urination is still at same rate.

Rest and Sleep Pattern

Prior to admission, patient sleeps at around 9 in the evening and wakes up at 5am to do
her farming chores. After farming, she usually does the house hold chores and has some naps when she’s
finished. She never used any sleeping aids or non pharmacologic management to induce sleep.

Presently, she stays at her bed and sleeps minimally due to episodes of cough and dyspnea.

Activity/Exercise/Lifestyle Patterns

The patient was a farmer, but because of her age, she can no longer work that long. Reportedly,
fumes and other minute particles from pesticides were inhaled. Patient was also a known smoker. She
started smoking and drinking at the age of 20. She smokes 1 pack of cigarette per day, approximately 15,
695 packs since 1965.

Presently, patient stays at her bed, self care and grooming activities were provided by her
daughter and other significant members of the family.
Respiratory pattern

Prior to admission patient suffers from productive cough. At night she usually suffers from
dyspnea which usually predisposes her to sleep deprivation and disturbance.

Presently, she minimally suffers from dyspnea. Nebulizations were done regularly to facilitate
liquefaction of secretions.

Hygiene and self care activities

Prior to admission patient does her personal grooming and self care activities. She regularly takes
a bath every day.

Presently, self care and grooming activities were provided by her daughter. Oral care activities
are usually seldom done. Sponge bathing was initiated by her daughter.

Roles and Relationship

Dyosa is now living with her daughter. She has 8 children and 7 of them were already married.
She claimed that she has no known conflict with other people.

Self Perception

Dyosa was able to express her feelings about her condition. The patient verbalized concerns
about her present condition and state that she doesn’t want to become the source of burden for the
family. She added that she still believes GOD will help her.

Coping/ Stress

She said that she’s not blaming anyone for her condition. She just accept and pray’s to God. She
believes that there are reason’s for everything. She believes that God has special plans for her. When she
is under stress she just relax and pray to God for the many things that will make her a better and stronger
individual.

Value/ Belief

The patient is affiliated to Roman Catholic. Her parents are YOGAD. She grew up at Pangal Norte,
Echague, Isabela. According to her, they have no practices or rites that could affect her health. Her source
of strength or meaning is God. She prays very hard that her condition will return to normal in the soonest
possible time.
 PHYSICAL ASSESSMENT

Received lying on bed with IVF of D5 LRs 1Lx8hrs infusing well, patent and intact. With complains of body
weakness and cough with latest vital signs of BP= 130/80 mmHg, RR= 30 cpm, PR= 124 bpm, Temp=
37.9C.

General appearance: weak looking, pale

On going IVF: D5 LR @ 1L x 8 hours

Vital Signs: Blood Pressure-130/80 mmHg Respiratory Rate-30cpm

Pulse Rate- 124 bpm Temperature-37.9C

Weght: 37kg height: 4’9

Date: December 10, 2008

BODY PARTS METHODS FINDINGS INTERPRETATION

Head

Skull Inspection Skull is symmetrical in Normal

shape.

No mass and tenderness

Palpation Normal
palpated.

Hair Inspection Due to aging process

White hair

Scalp Inspection Normal

(-) lesion

Due to poor hygiene

 (+) dandruff

Face Inspection Pallor Due to decreased oxygenation.

Normal

Inspection Pear in shape Due to aging process

Symmetrical and wrinkled

(+) Facial Sensation Normal

Palpation (-) mass Normal

Eyes Inspection Pale conjunctiva Due to decreased hemoglobin

Pupils Inspection Constrict with increasing Normal

light and accommodation

Eyeballs Inspection Moves in conjugate fashion Normal

Sclera Inspection Unicteric Normal

Nose Inspection No secretion noted; cilia Normal

hair is seen. Located in the
midline.

Ears Inspection No discharge. Normal

Hearing Cannot hear clearly in d/t aging process

modulate voice in both ears

Pinna Inspection Symmetrical, no lesion, Normal

above the outer cantus of
the eye

Ear canal Inspection Dry cerumen noted Normal

MOUTH

Lips Inspection dry lips due to inadequate hydration

gums Inspection dark in color Due to prolonged smoking

tongue Inspection Moist and no lesions Normal

>With white patches Due to poor oral care

TRACHEA Inspection located at midline (-) Normal

tracheal deviation

Neck Inspection With wrinkles noted can Normal

turn left and right, up and
down.

Palpation Normal
No mass and tenderness
palpated.

Chest Inspection Symmetrical Normal

Lungs Auscultation (+) Stridor and crackles Due to accumulation of

secretions in the upper airway

Upper Inspection Dry skin d/t poor hygiene

Extremities

(-) lesion Normal

*Hands are with same Normal

length.
 *long and dirty nails d/t poor hygiene

Palpation *Absence of edema, Normal

Poor skin turgor d/t aging process

No mass and tenderness Normal

palpated.

Date: October 06, 2008

HEMATOLOGY

Parameters Normal Values Results Interpretation

Hgb Male 140-170

Female 120-160 87 Decreased due to inability to

 partake iron rich foods.

Indicative of physiologic

anemia.

Hct Male .40-.51

Female .37-.48 .26 Decreased due to inability to

partake iron rich foods.

Indicative of physiologic

anemia.

WBCx10’9/L 5.0-10.0 16.7 Increased due to invasion of

microorganisms over

respiratory structures.

Indicative of bacterial

infection.

RBCx10’12/L

Plateletx10’9/L 140-440

Neutrophil % 55-65 68 Increased due to invasion of

microorganisms over

respiratory structures.

Indicative of bacterial

infection.

Lymphocyte % 25-40 27 Normal

Monocyte % 2-8 6 Normal

Eosinophil % 1-3

Band or Stab % 2-6 6 Normal

Date: October 08, 2008

HEMATOLOGY

Parameters Normal Values Results Interpretation

Hgb Male 140-170

Female 120-160 97 Decreased due to

inability to partake

iron rich foods.

Indicative of

physiologic anemia.

Hct Male .40-.51

Female .37-.48

WBCx10’9/L 5.0-10.0
RBCx10’12/L

Plateletx10’9/L 140-440

Neutrophil % 55-65

Lymphocyte % 25-40

Monocyte % 2-8

Eosinophil % 1-3

Band or Stab % 2-6

Date: October 07,2008

Serology and Blood Banking

Patients ABO & RH typing B+

Donor’s ABO & RH typing B+

Blood bag No. 08-1603

Date extraction 9/28/08

Date Expiration 11/1/08

Crossmatching

Major Compatible

Minor Compatible

Remarks Ok

Date: October 07,2008

 RADIOLOGY REPORT

Chest PA

- There is an in homogenous pacification in the right lower lung field.

- An ovoid density on mass is seen in the left perihilar area .

- Heart is not enlarge.

- Diaphragm and visualized bony structures are unremarkable.

Remarks

- Pneumonia- Right lower lung field

- Pulmonary mass, left perihilar area

- Suggest follow up chest x-ray

Bernardo Lingan MD, FPCP,FUSP

COURSE IN THE WARD

INITIAL VITAL SIGNS:

BP- 130/80 mmHg PR- 124 bpm

RR- 30 CPM Temp- 37.9 C

Date and time Doctor’s orders Interpretation

October 06, 2008 Admit to ROC To further manage present respiratory

condition
11:45AM

For autonomy and legality of purposes

Secure consent

To provide continuous monitoring of

V/S q 4hours present condition and to identify
response to respiratory therapy

To facilitate nutrition
DAT diet

To identify degree of pulmonary

CBC
infectious process

To identify pre-existing complication

Urinalysis related to compromise respiratory
condition.

To provide diagnostic overview of

Chest X-ray AP view present respiratory condition

To facilitate intravenous hydration. This

facilitates route for medicine
IVF D5LR 1L @32
administration
gtts/min
 Administer O2 @ 2L/m To facilitate oxygenation

Paracetamol 1amp for temperature 38.5 (PRN) To decrease body temperature related
to bacterial virulence and over
production of pyrogens.

Cefuroxime 750mg IV q8 ANST To facilitate wellness by decrease

bacterial pathogenecity.

Multivitamins 1g OD Vigor Ace

To provide supplemental nourishment

To prevent allergic reactions during

Antamin 1 amp IVP
blood transfusion
October 07, 2008

For blood transfusion 2 units of PRBC properly Due to decrease of hemoglobin count
typed and x matched
To ensure the compatibility of the
donor’s blood to the recipient’s

October 08, 2008 To determine blood values and to note

For repeat Hgb for the effects of the blood transfusion.

To facilitate hydration

D5LR 1L x 30 gtts/ min

To prevent or treat bronchospasm in

October 09, 2008 patients with reversible obstructive
Nebulization with salbutamol 1 neb q8 airway disease
October 10, 2008

HAMA To facilitate wellness by decrease

bacterial pathogenecity.
Cefuroxime axetil 500 BID

------------

Amoxol 30 mg TID

-------------
Salbutamol neb 1 neb q8

To provide supplemental nourishment

(multivitamins)
Ferrous sulfate OD

Respiratory System

Respiratory System, in anatomy and physiology, organs that deliver oxygen to the circulatory

system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to
liberate the energy needed for cellular activities. In addition to supplying oxygen, the respiratory system
aids in removing of carbon dioxide, preventing the lethal buildup of this waste product in body tissues.
Day-in and day-out, without the prompt of conscious thought, the respiratory system carries out its life-
sustaining activities. If the respiratory system’s tasks are interrupted for more than a few minutes,
serious, irreversible damage to tissues occurs, followed by the failure of all body systems, and ultimately,
death.

While the intake of oxygen and removal of carbon dioxide are the primary functions of the
respiratory system, it plays other important roles in the body. The respiratory system helps regulate the
balance of acid and base in tissues, a process crucial for the normal functioning of cells. It protects the
body against disease-causing organisms and toxic substances inhaled with air. The respiratory system also
houses the cells that detect smell, and assists in the production of sounds for speech.

The respiratory and circulatory systems work together to deliver oxygen to cells and

remove carbon dioxide in a two-phase process called respiration. The first phase of respiration
begins with breathing in, or inhalation. Inhalation brings air from outside the body into the
lungs. Oxygen in the air moves from the lungs through blood vessels to the heart, which pumps
the oxygen-rich blood to all parts of the body. Oxygen then moves from the bloodstream into
cells, which completes the first phase of respiration. In the cells, oxygen is used in a separate
energy-producing process called cellular respiration, which produces carbon dioxide as a
byproduct. The second phase of respiration begins with the movement of carbon dioxide from
the cells to the bloodstream. The bloodstream carries carbon dioxide to the heart, which pumps
the carbon dioxide-laden blood to the lungs. In the lungs, breathing out, or exhalation, removes
carbon dioxide from the body, thus completing the respiration cycle.

II STRUCTURE

The organs of the respiratory system extend from the nose to the lungs and are divided
into the upper and lower respiratory tracts. The upper respiratory tract consists of the nose and
the pharynx, or throat. The lower respiratory tract includes the larynx, or voice box; the trachea,
or windpipe, which splits into two main branches called bronchi; tiny branches of the bronchi
called bronchioles; and the lungs, a pair of saclike, spongy organs. The nose, pharynx, larynx,
trachea, bronchi, and bronchioles conduct air to and from the lungs. The lungs interact with the
circulatory system to deliver oxygen and remove carbon dioxide.

A Nasal Passages

The flow of air from outside of the body to the lungs begins with the nose, which is divided into
the left and right nasal passages. The nasal passages are lined with a membrane composed primarily of
one layer of flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with
thousands of microscopic cilia, fingerlike extensions of the cells. Interspersed among the epithelial cells
are goblet cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial
cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the mucous membrane,
near the surface of the nasal passages. While transporting air to the pharynx, the nasal passages play two
critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and
warm the air to protect the structures in the respiratory system.
 Filtering prevents airborne bacteria, viruses, other potentially disease-causing substances from
entering the lungs, where they may cause infection. Filtering also eliminates smog and dust particles,
which may clog the narrow air passages in the smallest bronchioles. Coarse hairs found just inside the
nostrils of the nose trap airborne particles as they are inhaled. The particles drop down onto the mucous
membrane lining the nasal passages. The cilia embedded in the mucous membrane wave constantly,
creating a current of mucus that propels the particles out of the nose or downward to the pharynx. In the
pharynx, the mucus is swallowed and passed to the stomach, where the particles are destroyed by
stomach acid. If more particles are in the nasal passages than the cilia can handle, the particles build up
on the mucus and irritate the membrane beneath it. This irritation triggers a reflex that produces a sneeze
to get rid of the polluted air.

The nasal passages also moisten and warm air to prevent it from damaging the delicate
membranes of the lung. The mucous membranes of the nasal passages release water vapor, which
moistens the air as it passes over the membranes. As air moves over the extensive capillaries in the nasal
passages, it is warmed by the blood in the capillaries. If the nose is blocked or “stuffy” due to a cold or
allergies, a person is forced to breathe through the mouth. This can be potentially harmful to the
respiratory system membranes, since the mouth does not filter, warm, or moisten air.

In addition to their role in the respiratory system, the nasal passages house cells called olfactory
receptors, which are involved in the sense of smell. When chemicals enter the nasal passages, they
contact the olfactory receptors. This triggers the receptors to send a signal to the brain, which creates the
perception of smell.

B Pharynx

Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube

about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is
lined with a protective mucous membrane and ciliated cells that remove impurities from the air.
In addition to serving as an air passage, the pharynx houses the tonsils, lymphatic tissues that
contain white blood cells. The white blood cells attack any disease-causing organisms that
escape the hairs, cilia, and mucus of the nasal passages and pharynx. The tonsils are strategically
located to prevent these organisms from moving further into the body. One tonsil, called the
adenoids, is found high in the rear wall of the pharynx. A pair of tonsils, the palatine tonsils, is
located at the back of the pharynx on either side of the tongue. Another pair, the lingual tonsils,
is found deep in the pharynx at the base of the tongue. In their battles with disease-causing
organisms, the tonsils sometimes become swollen with infection. When the adenoids are
swollen, they block the flow of air from the nasal passages to the pharynx, and a person must
breathe through the mouth.

C Larynx
 Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located
approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise
most of the larynx. A protrusion in the cartilage called the Adam’s apple sometimes enlarges in males
during puberty, creating a prominent bulge visible on the neck.

While the primary role of the larynx is to transport air to the trachea, it also serves other
functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air
passage to cause choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the
larynx waft airborne particles up toward the pharynx to be swallowed.

Food and fluids from the pharynx usually are prevented from entering the larynx by the
epiglottis, a thin, leaflike tissue. The “stem” of the leaf attaches to the front and top of the larynx. When a
person is breathing, the epiglottis is held in a vertical position, like an open trap door. When a person
swallows, however, a reflex causes the larynx and the epiglottis to move toward each other, forming a
protective seal, and food and fluids are routed to the esophagus. If a person is eating or drinking too
rapidly, or laughs while swallowing, the swallowing reflex may not work, and food or fluid can enter the
larynx. Food, fluid, or other substances in the larynx initiate a cough reflex as the body attempts to clear
the larynx of the obstruction. If the cough reflex does not work, a person can choke, a life-threatening
situation. The Heimlich maneuver is a technique used to clear a blocked larynx (see First Aid). A surgical
procedure called a tracheotomy is used to bypass the larynx and get air to the trachea in
extreme cases of choking.

D Trachea, Bronchi, and Bronchioles

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6 in) long

located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy
cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-
shaped cartilage lies at the back of the trachea, and the ends of the “C” are connected by muscle tissue.

The base of the trachea is located a little below where the neck meets the trunk of the body.
Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right
lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The
trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory
system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to
the pharynx.

E Alveoli
Human Lungs
In humans the lungs occupy a large portion of the chest cavity from the collarbone down to the
diaphragm. The right lung is divided into three sections, or lobes. The left lung, with a cleft to
accommodate the heart, has only two lobes. The two branches of the trachea, called bronchi, subdivide
within the lobes into smaller and smaller air vessels known as bronchioles. Bronchioles terminate in
alveoli, tiny air sacs surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses
into the blood in the capillaries to be pumped by the heart to the tissues of the body. At the same time
carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.

The bronchioles divide many more times in the lungs to create an impressive tree with smaller
and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into
tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide.
Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli
and remove foreign substances that have not been filtered out earlier. The macrophages are the last line
of defense of the respiratory system; their presence helps ensure that the alveoli are protected from
infection so that they can carry out their vital role.

Alveoli

The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli
resemble tiny, collapsed balloons with thin elastic walls that expand as air flows into them and collapse
when the air is exhaled. Alveoli are arranged in grapelike clusters, and each cluster is surrounded by a
dense hairnet of tiny, thin-walled capillaries. The alveoli and capillaries are arranged in such a way that air
in the wall of the alveoli is only about 0.1 to 0.2 microns from the blood in the capillary. Since the
concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the
alveoli to the capillaries. The oxygen flows through the capillaries to larger vessels, which carry the
oxygenated blood to the heart, where it is pumped to the rest of the body.

Carbon dioxide that has been dumped into the bloodstream as a waste product from

cells throughout the body flows through the bloodstream to the heart, and then to the alveolar
capillaries. The concentration of carbon dioxide in the capillaries is much higher than in the
alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation forces the carbon dioxide
back through the respiratory passages and then to the outside of the body.

III REGULATION

Diaphragm and Respiration

As the diaphragm contracts and moves downward, the pectoralis minor and intercostal
muscles pull the rib cage outward. The chest cavity expands, and air rushes into the lungs through the
trachea to fill the resulting vacuum. When the diaphragm relaxes to its normal, upwardly curving
position, the lungs contract, and air is forced out.

The flow of air in and out of the lungs is controlled by the nervous system, which ensures that
humans breathe in a regular pattern and at a regular rate. Breathing is carried out day and night by an
unconscious process. It begins with a cluster of nerve cells in the brain stem called the respiratory center.
These cells send simultaneous signals to the diaphragm and rib muscles, the muscles involved in
inhalation. The diaphragm is a large, dome-shaped muscle that lies just under the lungs. When the
diaphragm is stimulated by a nervous impulse, it flattens. The downward movement of the diaphragm
expands the volume of the cavity that contains the lungs, the thoracic cavity. When the rib muscles are
stimulated, they also contract, pulling the rib cage up and out like the handle of a pail. This movement
also expands the thoracic cavity. The increased volume of the thoracic cavity causes air to rush into the
lungs. The nervous stimulation is brief, and when it ceases, the diaphragm and rib muscles relax and
exhalation occurs. Under normal conditions, the respiratory center emits signals 12 to 20 times a minute,
causing a person to take 12 to 20 breaths a minute. Newborns breathe at a faster rate, about 30 to 50
breaths a minute.

The rhythm set by the respiratory center can be altered by conscious control. The breathing

pattern changes when a person sings or whistles, for example. A person also can alter the breathing
pattern by holding the breath. The cerebral cortex, the part of the brain involved in thinking, can send
signals to the diaphragm and rib muscles that temporarily override the signals from the respiratory
center. The ability to hold one’s breath has survival value. If a person encounters noxious fumes, for
example, it is possible to avoid inhaling the fumes.

A person cannot hold the breath indefinitely, however. If exhalation does not occur, carbon

dioxide accumulates in the blood, which, in turn, causes the blood to become more acidic. Increased
acidity interferes with the action of enzymes, the specialized proteins that participate in virtually all
biochemical reaction in the body. To prevent the blood from becoming too acidic, the blood is monitored
by special receptors called chemoreceptors, located in the brainstem and in the blood vessels of the neck.
If acid builds up in the blood, the chemoreceptors send nervous signals to the respiratory center, which
overrides the signals from the cerebral cortex and causes a person to exhale and then resume breathing.
These exhalations expel the carbon dioxide and bring the blood acid level back to normal.

A person can exert some degree of control over the amount of air inhaled, with some limitations.
To prevent the lungs from bursting from overinflation, specialized cells in the lungs called stretch
receptors measure the volume of air in the lungs. When the volume reaches an unsafe threshold, the
stretch receptors send signals to the respiratory center, which shuts down the muscles of inhalation and
halts the intake of air.

DISCHARGE PLANNING

Medications

1. Advised patient and significant others to take medications as prescribed.

2. Teach client to take all antibiotics with food to avoid gastrointestinal
upsets.
3. Take antibiotics up to the date of prescription to prevent bacterial
relapses.

Diet

1. Advise patient to eat regularly with adequate amounts of food.

2. Encourage patient to increase oral fluid intake to facilitate liquefaction of
secretions.
3. Advise significant others to offer foods rich in protein to facilitate
respiratory tissue repair.
4. Provide dietary education regarding alternate nutritional sources.

Lifestyle.

1. Advise patient to quit smoking and drinking alcohol.

2. Provide organized schedule of activities.

Rest and sleep

1. Offer adequate rest periods to facilitate regain of physical strength.

2. Encourage rest after occurrence of coughing activities.
3. Provide proper positioning during episodes of dyspnea.
4. Elevate head of the bed

Hygiene and grooming activities

 1. Encourage daily bathing as soon as patient can tolerate.
2. Provide and advise oral care to prevent reinfestation of microorganism
present in phlegm.

Environmental modification

1. Provide therapeutic environment free from over stimulation.

2. Offer environment free from dust and other related particles which can
stimulate coughing activity.
3. Provide education regarding proper disposal of sputum to prevent spread
of respiratory disease.